Updated Health Form 2022 - John W. Bass Plastic Surgeon

JOHN W. BASS, M.D., PLASTIC SURGERYJOHN W. BASS, M.D. PLASTIC SURGERY
(602) 485-1010
Health Information as of *

(Please Print Legibly & Fill In or Correct All Fields)
Patient’s Name *
Date of Birth: *
Add only if New Address or Phone
Address (Street & Apt )
City
State
Zip
Home Phone
Cell Phone
Other Phone
Any restrictions for contacting you?
No Yes
E-mail
1. Any new Allergies to drugs?
Yes No
If yes, what drug and describe symptoms
2. Any New Non-Drug allergies (food, environmental, etc)
3. Please list any surgeries since last visit
4. Date of Last Physical
5. List all medication you are now taking including birth control pills:
Name
Dose/Frequency
Reason for Taking Medication
6. Please list any new diagnoses since last visit
Facial Procedures
Breast Procedures
Body Procedures
Other Procedures
Signature *
Date *

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